Category Archives: Hepato-Biliary-Pancreatic

Pancreatic cystic neoplasms

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Scholten L, et al. Pancreatic Cystic Neoplasms: Different Types, Different Management, New Guidelines. Visc Med. 2018 Jul;34(3):173-177.

Pancreatic cystic neoplasms (PCN) include different types of cysts with various biological behavior. The most prevalent PCN are intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), and serous cystic neoplasm (SCN). Management of PCN should focus on the prevention of malignant progression, while avoiding unnecessary morbidity of surgery. This requires specialized centers with dedicated multidisciplinary PCN teams. The malignant potential of PCN varies enormously between the various types of PCN. A combination of computed tomography, magnetic resonance imaging/magnetic resonance cholangiopancreatography, and endoscopic ultrasound with or without fine needle aspiration is typically needed before a reliable diagnosis can be made. Several guidelines discuss the management of PCN; however, most of these are non-evidence-based without clear consensus on the optimal treatment and follow-up strategy. The 2018 European guidelines on PCN are the first evidence-based guidelines to include IPMN, MCN, SCN, and all other PCN. This guideline advises a more conservative approach to side-branch IPMN and MCN smaller than 40 mm and more often a surgical approach in IPMN with a main duct dilatation beyond 5 mm. The goal of this review is to summarize the different types and management of the most common PCN based on the current literature and guidelines.

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Obstructive jaundice and coagulation disturbances

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Pavlidis ET, Pavlidis TE. Pathophysiological consequences of obstructive jaundice and perioperative management. Hepatobiliary Pancreat Dis Int. 2018 Feb;17(1):17-21.

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“Proper management includes full replacement of water and electrolyte deficiency, prophylactic antibiotics, lactulose, vitamin K and fresh frozen plasma, albumin and dopamine. The preoperative biliary drainage has not been indicated in overall, but only in a few selected cases.”

“The coagulation disorders and the resulting hemostasis impairment have been attributed to the complement activation by endotoxin as well as to the reduced synthesis of prothrombin (factor II) in the liver and the other vitamin K depended coagulation factors i.e. VII, IX, X and proteins C, S, Z. The absence of bile salts in the gut prevents the absorption of vitamin K, which is a fat-soluble vitamin. In addition, the endogenous microbial flora produces small amounts of vitamin K. Subsequently the reduced vitamin K absorption results in its deficiency. The latter predisposes to bleeding diathesis, despite the normal laboratory indices such as prothrombin time (PTT) and international normalized ratio (INR). Likewise, the other fat-soluble vitamin D and lipids absorption is diminished resulting in their deficiency and calcium reduction.” (Pavlidis, et al., p. 19.)

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Pancreaticoduodenectomy in patients with previous Roux-en-Y gastric bypass

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Shah MM, Martin BM, Stetler JL, Patel AD, Davis SS, Sarmiento JM, Lin E. Reconstruction Options for Pancreaticoduodenectomy in Patients with Prior Roux-en-Y Gastric Bypass. J Laparoendosc Adv Surg Tech A. 2017 Nov;27(11):1185-1191.

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“In summary, of the 13 patients that have been described in the literature who underwent PD after RYGB, 7 (54%) of these patients underwent reconstruction, similar to our preferred approach (Fig. 2), which involved remnant gastrectomy with the BP limb forming the BP anastomoses. Overall, 8 (61.5%) of the 13 patients had remnant gastrectomy. Five patients did not have a remnant gastrectomy. There are 10 patients in the literature where the surgeon attempted resecting the gastric remnant, and 8 (80%) of these patients had successful remnant gastrectomy. However, based on the published literature, this is clearly a small sampling of what might have actually been performed. We have had three such patients where we performed PD in patients with prior RYGB (similar to Fig. 2a). In all patients, we had adequate BP limb length for the anastomoses. The patients had early recovery of bowel function and were discharged from the hospital on or before postoperative day 5 without any significant complications. Continue reading →

Liver hanging maneuver: an anatomic and clinical review.

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Gaujoux S, et al. Liver hanging maneuver: an anatomic and clinical review. Am J Surg. 2007 Apr;193(4):488-92.

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“LHM is as an effective and safe method of guiding hepatic transection to the IVC during right hepatectomies with a feasibility rate up to 95% and minor bleeding in 0% to 6% of cases. According to small series and experts’ opinions, LHM would improve parenchymal transection by reducing operative time and blood loss. The tape would ensure a linearly cut surface with IVC safer protection, better exposure, and hemostasis of the deeper plane. Limited remnant liver mobilization could reduce the risk for malignant dissemination and improve liver function. Hepatectomies for huge tumor with diaphragm adhesions could be facilitated.”

Glissonian approach during hepathectomy

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Chapuis-Roux E, et al. Glissonian approach during hepathectomy (with video). J Visc Surg. 2015 Jun;152(3):199-200.

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“To facilitate liver resection, a technique of glissonian approach was developed [2]. The glissonian approach during hepatectomy is a selective vascular clamping procedure reproducible requiring preoperative imaging data study and intraoperative ultrasound Doppler [3] and permeability with US air test [4]. In practice, this approach is feasible in about 80% of patients due to portal anatomical abnormalities.”

Bile Cultures are Poor Predictors of Antibiotic Resistance in Postoperative Infections Following Pancreaticoduodenectomy

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Maxwell DW, Jajja MR, Ferez-Pinzon A, Pouch SM, Cardona K, Kooby DA, Maithel SK, Russell MC, Sarmiento JM. Bile cultures are poor predictors of antibiotic resistance in postoperative infections following pancreaticoduodenectomy.HPB (Oxford). 2019 Oct 26:S1365-182X(19)30756-7.

Results: Common patient characteristics of 522 included patients were 65-years-old, Caucasian (75.5%), male (54.2%), malignant indication (79.3%), and preoperative biliary stent (59.0%). Overall, 275 (89.6%) BCs matured identifiable isolates with 152 (55.2%) demonstrating polymicrobial growth. Ninety-two (17.6%) SOICs were obtained: 48 and 44 occurred in patients with and without intraoperative BCs. Stents were associated with bacteriobilia (85.7%, K = 0.947, p < 0.001; OR 22.727, p < 0.001), but not postoperative infections (15.2%; K = 0.302, p < 0.001; OR 1.428, p = 0.122). Forty-eight patients demonstrated paired BC/SOICs to evaluate. Pathogenic concordance of this group was 31.1% (K = 0.605, p < 0.001) while SRP concordance of matched pathogens was 46.7% (K = 0.167, p = 0.008).

Conclusion: Bile cultures demonstrate poor concordance with the susceptibility/resistance patterns of postoperative infections following pancreaticoduodenectomy and may lead to inappropriate antibiotic therapies.